Enchanted Garden for Seniors

Type of visit: Required - 1 Year

On 07/29/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with Assistant Administrator Lolita Factolerin and explained the purpose of today's visit. There are currently 5 residents in the facility and 4 staff present. This is a single level facility, licensed for residents age range of 60 years and over all of which may be non-ambulatory. Hospice waiver on file. There is one hospice resident at this time. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in a kitchen drawer adjacent to the sink. Medications are locked in a cabinet adjacent to a double door that leads to the exterior patio. Perishable and non-perishable food items are observed as in place. Main kitchen has refrigerator which is functioning is observed with fresh food supplies in place. There are is one additional refrigerator in the garage for additional facility food supplies. Non-perishable food/emergency food supplies are in place. First aid kit is observed as complete with required items stored in a hallway cabinet. LPA observed that there are 3 fire extinguishers in place inspected on 06/09/2026, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central HVAC. Fire pull stations are located in the main hallway at both ends of the hallway. Laundry area is observed as fully operational, and lockable, in the garage of the facility. Continued on next page... Page 2 Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 08/02/2026 per file review. Water temperature is measured at 109F. Cleaning supplies are observed to be locked beneath the kitchen sink and additional toxins and cleaning supplies are observed to be locked in additional cabinets. This facility does not have fire sprinklers on site. LPA observed all resident rooms and all are observed as clean, free of odors, and contained all the required furniture per regulatory recommendations. There is one staff room in the facility accessible by a door in the common hallway and through the dining room area. Resident linen supplies are observed as in place stored in a hallway cabinet. There is one common full bathroom located at the end of the common hallway central to resident rooms. Shower floor does have non-skid surfacing but a non-skid mat is present for use. During today's inspection LPA reviewed 5 resident files and 6 staff files during today's inspection. 2 of 6 staff files did not have current CPR/First Aid training. Training hours are on file for staff dated in 2026. 1 of 5 resident files did not have current LIC602 or evidence of medical appraisal since 2025. Medications are inspected and are accurate to what is listed on centrally stored medication and destruction record. Administrator certificate is current expiring on 07/28/2027. The following updated forms are requested to be submitted to CCLD by 08/26/2025: • Copy of updated administrator certificate • Copy of facility's liability insurance • LIC500 Staff Schedule • Copy of control of property No citations issued on this day. Report is reviewed with administrator assistant Lolita Factolerin and a copy is provided on this day.the state’s words, verbatim · CDSS document, Aug 19, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Aug 26, 2026

REAPPRAISALS The pre-admission appraisa... shall be updated in writing as frequently as necessary or once every 12 months...to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. This regulation has not been met as evidenced by: Based on resident file reviews, R5 diagnosed with dementia, is dated more than 12 months ago. Facility failed to ensure that appraisals are completed annually, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: Reappraisals shall be completed for R5, in the form of a physicians visit or updated LIC602, to maintain complaince with this regulation copies will be sent to the Department by due date stated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Aug 26, 2026

PERSONNEL REQUIREMENTS Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement has not been met as evidenced by: Based on staff files reviewed, 2 out of 6 staff first aid cards are not current, both expiring in January 2026 Licensee failed to ensure that staff whothe state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: First aid training for staff #1 and #6 shall be completed, to maintain complaince with this regulation, copies will be sent to the Department by due date stated.

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds. This one level facility consists of 5 client rooms--all of which have private half bathrooms and exits--a staff room with one bed, bath/shower room, living and dining rooms, kitchen, and attached 1 car garage. Two residents currently receive hospice services. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete. Medications are stored in locked cabinet in dining room. Chemicals and cleaners are stored in garage and locked kitchen cabinet. The backyard is fenced and gated; all bedrooms access wood ramp. Client and staff records are reviewed. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Training records and medications may be reviewed at a later date. Ferlene Giusto is a certified RCFE administrator (x 7/25) that oversees facility operations. The following information is provided to LPA today: - updated Personnel Report (LIC500) Proof of current liability insurance to be sent to CCLD BY 7/8/25. Deficiencies of the California Code of REgulations, Title 22 are cited on a following pages. See page TWO for Hospice Care Plan requirements. HOSPICE CARE OF TERMINALLY ILL RESIDENTS A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (1) The name, office address, business telephone number, and 24-hour emergency telephone number of the hospice agency and the resident's physician. (2) A description of the services to be provided in the facility by the hospice agency including but not limited to the type and frequency of services to be provided. (3) Designation of the resident's primary contact person at the hospice agency, and resident's primary and alternate care giver at the facility. (4) A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility. (A) The plan shall specify all procedures to be implemented by the licensee regarding the storage and handling of medications or other substances, and the maintenance and use of medical supplies, equipment, or appliances. (B) The plan shall specify, by name or job function, the licensed health care professional on the hospice agency staff who will control and supervise the storage and administration of all controlled drugs (Schedule II - V) for the hospice client. Facility staff can assist hospice residents with self-medications without hospice personnel being present. (C) The plan shall neither require nor recommend that the licensee or any facility personnel other than a physician or appropriately skilled professional implement any health care procedure which may legally be provided only by a physician or appropriately skilled professional. (5) A description of all hospice services to be provided or arranged in the facility by persons other than the licensee, facility personnel, or the hospice agency including, but not limited to, clergy and the resident's family members and friends. (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan. (A) The training shall include but not be limited to typical needs of hospice patients, such as turning and incontinence care to prevent skin breakdown, hydration, and infection control. (B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins. (7) Any other information deemed necessary by the Department to ensure that the terminally ill resident’s needs for health care, personal care, and supervision are met.the state’s words, verbatim · CDSS document, Jun 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(c)(1)(2) · Plan of correction due date: Jun 25, 2025

CRIMINAL RECORD CLEARANCE A licensee ...may request a transfer of a criminal record clearance from one state licensed facility to another...state licensed facility by providing the following... to the Dept: signed ... LIC 9182, a copy of the individual's driver's license, or valid ID card issued by the DMV or valid photo ID issued by another state or the U.S. government if the individual is not a CA resident. This requirement is not met, as 3 out of 15 staff do not have criminal record clearance associated to facility. Criminal record clearances for Staff #1, #2, #3 must be transferrred to this facility.the state’s words, verbatim · CDSS document, Jun 24, 2025

Plan of correction: Criminal record clearances for 3 staff will be transferred to this facility and proof of correction to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Jul 8, 2025

REAPPRAISALS The pre-admission appraisa... shall be updated in writing as frequently as necessary or once every 12 months...to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. This requirement is not met, as appraisals for clients #3 and #4--who are diagnosed with dementia--are dated more than 12 months ago. Licensee failed to ensure that appraisals are completed annually, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jun 24, 2025

Plan of correction: Reappraisals will be completed for clients #3 and #4 and copies will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Jul 8, 2025

POSTURAL SUPPORTS A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met, as there are no MD orders maintained for clients #3 and #5, who have half bed rails. This poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jun 24, 2025

Plan of correction: MD orders will be sent to CCLD BY DUE DATE for half bed rails for clients #3 and #5

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(b) · Plan of correction due date: Jul 8, 2025

HOSPICE CARE See Page 2 for regulation . This requirement was not met, as ANX hospice care plan for client #1 is incomplete. Licensee failed to ensure that complete hospice care plans are maintained, which poses a potential health, safety or presonal rights risk.the state’s words, verbatim · CDSS document, Jun 24, 2025

Plan of correction: Complete hospice care plan for client #1 to be sent to CCLD BY DUE DATE.

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds. This one level facility consists of 5 client rooms--all of which have private half bathrooms and exits--a staff room with one bed, bath/shower room, living and dining rooms, kitchen, and attached 1 car garage. Four residents currently receive hospice services. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete. Medications are stored in locked cabinet in dining room. Chemicals and cleaners are stored in garage and locked kitchen cabinet. The backyard is fenced and gated; all bedrooms access wood ramp. Client and staff records are reviewed. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Ferlene Giusto is a certified RCFE administrator (x 7/25) that oversees facility operations. The following information is provided to LPA today: - Updated Disaster and Mass Casualty Plan (LIC610E) - Current proof of liability insurance for $1 million per incident and $3 million in annual aggregate - Designation of Facility Responsiblity (LIC308) Deficiencies of the California Code of REgulations, Title 22 are cited on a following page. See also Technical Advisory Notes--5 pages.the state’s words, verbatim · CDSS document, Jul 11, 2024